Citation Nr: 1627564 Decision Date: 07/12/16 Archive Date: 07/22/16 DOCKET NO. 11-30 458 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for narcolepsy. 2. Entitlement to an initial disability rating in excess of 10 percent for posttraumatic stress disorder (PTSD) with attention deficit hyperactivity disorder (ADHD), from September 16, 2009, to December 7, 2011. 3. Entitlement to a disability rating in excess of 70 percent for PTSD with ADHD, from December 7, 2011. 4. Entitlement to a total disability rating based on unemployability (TDIU) due to service-connected PTSD with ADHD prior to December 7, 2011, to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active military service from January 1980 to December 1983. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2011 rating decision in which the RO granted service connection and assigned an initial 10 percent rating for PTSD with ADHD, effective September 16, 2009 (the date of the claim for service connection), and denied the Veteran's claim for service connection for narcolepsy. In June 2011, the Veteran filed a notice of disagreement (NOD) with the initial rating assigned for PTSD with ADHD and with the denial of service connection for narcolepsy. In October 2011, the RO issued a statement of the case (SOC), and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to Board of Veterans' Appeals) in November 2011. During the pendency of this appeal, in an August 2013 supplemental SOC (SSOC), the RO granted a higher, 70 percent rating for PTSD with ADHD from December 7, 2011. As higher ratings for this disability are assignable, and the Veteran is presumed to seek the maximum available benefit, the Board has characterized the appeal pertaining to evaluation of his PTSD with ADHD as encompassing the second and third matters as set forth on the title page. Id.; AB v. Brown, 6 Vet. App. 35, 38 (1993). In December 2011, the Veteran submitted evidence that included a private physician's opinion that the Veteran is unemployable due to service-connected PTSD with ADHD, which was deemed to raise the matter of the Veteran's entitlement to a TDIU due to PTSD with ADHD as a component of his claim for a higher initial rating for PTSD with ADHD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a June 2013 rating decision, the RO awarded the Veteran a TDIU, effective from December 7, 2011-the date the private medical opinion was received by VA. Hence, the matter of the Veteran's entitlement to a TDIU prior to that date remains for the Board's consideration. This appeal is now being processed utilizing the Veterans Benefits Management System (VBMS), a paperless, electronic claims processing system. The Veteran also has a separate paperless, electronic Virtual VA file. A review of the Virtual VA file reveals that it contains records of the Veteran's ongoing treatment with VA providers. Otherwise, the documents are either duplicative of those contained in the VBMS file or irrelevant to the issues on appeal. The Board's decision denying service connection for narcolepsy, granting an initial 50 percent rating for PTSD with ADHD from September 16, 2009, to December 7, 2011, and denying a rating in excess of 70 percent for PTSD from December 7, 2011, is set forth below. The matter of the Veteran's entitlement to a TDIU due to PTSD with ADHD prior to December 7, 2011, to include on an extra-schedular basis, is addressed in the remand following the order; this matter is being remanded to the AOJ. VA will notify the Veteran when further action, on his part, is required. The Board acknowledges that in September 2011, the Veteran submitted documentation indicating that he wished to file a motion to advance his appeal on the docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2014) and 38 C.F.R. § 20.900(c) (2015). This documentation consisted of a statement that he wished his claim to be expedited due to "financial hardship," along with a statement from his landlord indicating that he was in arrears for utilities in the approximate amount of $182.00. The Board points out, however, that general financial difficulties do not meet the standard for severe financial hardship to warrant advancement on the docket. In that connection, the Board notes that severe financial hardship contemplates a profound situation, such as a pending bankruptcy or home foreclosure, where the hardship might be relieved in whole or in part if the benefit sought on appeal were to be granted. In this case, however, no such severe hardship has been shown; thus, the motion is denied. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. There is no competent, probative evidence indicating that the Veteran currently has, or at any time pertinent to the claim on appeal has had, diagnosed narcolepsy. 3. From the September 16, 2009, effective date of the award of service connection, to December 7, 2011, the Veteran's PTSD with ADHD was manifested by symptoms including anxiety; anger and irritability; difficulty establishing and maintaining effective relationships; chronic sleep disturbances; social isolation and avoidance; constricted affect; and problems with attention and concentration. Collectively, these symptoms are of the type and extent, frequency, and/or severity (as appropriate) to suggest occupational and social impairment with reduced reliability and productivity. 4. Since December 7, 2011, the Veteran's PTSD with ADHD has been manifested by symptoms including depressed mood, feelings of detachment; lack of interest in activities; mild memory loss; impaired judgment; restricted affect; anxiety; anger and irritability; chronic sleep disturbances, including nightmares; impaired concentration and focus; an inability to establish and maintain effective relationships; difficulty adapting to stressful circumstances; and social isolation and avoidance behaviors. Collectively, these symptoms are of the type and extent, frequency, and/or severity (as appropriate) that are indicative of no more than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. 5. The applicable schedular criteria are adequate to rate the Veteran's PTSD at all pertinent points. CONCLUSIONS OF LAW 1. The criteria for service connection for narcolepsy are not met. 38 U.S.C.A. § 1110, 1131 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 50 percent rating for PTSD with ADHD, from September 16, 2009, to December 7, 2011, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2015). 3. The criteria for a rating in excess of 70 percent for PTSD with ADHD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-56 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), a well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ (here, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In February 2010 and July 2010 pre-rating letters, the RO provided notice to the Veteran regarding the information and evidence needed to substantiate his claims for service connection. These letters also informed the Veteran of what information and evidence must be submitted by him, and what information and evidence would be obtained by VA. In addition, the letters provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After the award of service connection for PTSD with ADHD, and receipt of the Veteran's disagreement with the initial rating assigned, no additional notice for the downstream, initial rating issue was required under 38 U.S.C.A. § 5103A. See VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004)). Nevertheless, the October 2011 SOC includes citation to the full rating criteria for evaluating PTSD and the provisions of 38 C.F.R. § 3.321, governing extra-schedular consideration (the timing and form of which suffices, in part, for Dingess/Hartman). As for VA's duty to assist, the record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file includes the Veteran's VA treatment records and private treatment records, as well as records of the Veteran's application for disability benefits from the Social Security Administration (SSA). The Veteran has also been provided multiple VA examinations concerning his claim for increase, most recently in May 2013. The adequacy of these VA examinations has not been challenged. The Board notes that VA has not arranged for VA medical examination and/or opinion in connection with the claim for service connection for narcolepsy; however, as explained in more detail below, no such examination and opinion is required. Also of record and considered in connection with these claims are various written statements provided by the Veteran and his representative, on his behalf. The Board finds that no further AOJ action to develop these claims, prior to appellate consideration, is required. The Board acknowledges that there are no service treatment records for the Veteran in the record. After requesting them in conjunction with the instant claims, the AOJ was informed in June 2010 that there were no service treatment records available. Here, the Board finds that the AOJ has undertaken appropriate actions in attempting to obtain service records, including efforts undertaken to reconstruct such records. In a July 2010 letter, the AOJ informed the Veteran that his service records were unable to be found. He was asked to furnish any service records he had in his possession. Given the missing service treatment records, VA has a heightened duty to assist the Veteran in development of his claim. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The AOJ met this heightened duty here, advising the Veteran of the lack of availability of his service treatment records; informing him of the alternative forms of evidence that can be developed to substantiate the claim; and otherwise expending exhaustive efforts to obtain the Veteran's service treatment records. As such, no further AOJ action in this regard is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of any matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis A. Claim for Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in line of duty. See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). The requirement of the existence of a current disability is satisfied when a veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2015). See also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contends that he suffers from narcolepsy as a result of his time in service. As stated above, the Veteran's service treatment records are unavailable. However, the Veteran has not identified or submitted any post-service treatment records that contain a diagnosis of narcolepsy. In this regard, the Board notes that, in December 2009, the Veteran underwent a psychological evaluation in connection with his claim for SSA disability benefits in which he reported having "sleep problems with insomnia and narcolepsy (he stated that he would sleep excessively)." However, the psychologist who examined him at that time did not assign a diagnosis of narcolepsy, nor is there any diagnosis of narcolepsy made by a medical professional at any time during the appeal period. Despite the evidence showing the Veteran has occasionally complained of problems sleeping, the evidence reflects that these complaints have been attributed to his service-connected PTSD with ADHD. In fact, the Board finds probative that, while the evidentiary record contains VA treatment records documenting the Veteran's complaints regarding various disabilities, the VA treatment records do not contain any objective medical evidence that documents any treatment or diagnostic studies that confirm the presence of narcolepsy since the Veteran was discharged from service to the present. In this regard, the Board notes the Veteran is competent to report that he experiences problems sleeping; however, such a report, without more, is not considered a competent diagnosis of disability. Moreover, it is not argued or shown that the Veteran is qualified through specialized education, training, or experience to render a diagnosis of narcolepsy. Therefore, the Veteran's lay assertions, alone, do not provide competent, persuasive evidence of the claimed narcolepsy. Additionally, as noted, with the single exception discussed above, the evidentiary record includes no VA or private treatment records that document any complaints, findings or diagnosis pertinent to narcolepsy, and the Veteran has not presented or identified any existing medical record(s) documenting any complaints, findings, or diagnosis of narcolepsy. To the contrary, the Veteran's reported sleep problems have consistently been attributed to his service-connected PTSD with ADHD. In short, there is no competent medical evidence of any narcolepsy at any point pertinent to this appeal. Furthermore, although the Veteran has not afforded a VA examination and no medical opinion has otherwise been obtained with respect to this claim, the Board finds that the claim does not meet the fundamental requirements necessary to obtain such an examination or opinion. Generally, VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2) (West 2014); 38 C.F.R. § 3.159(c)(4)(i) (2015); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As indicated, the evidence does not show the Veteran has been diagnosed with narcolepsy during, or at any point in close proximity, to this appeal. Moreover, there is no medical evidence of record that shows the Veteran has reported any symptoms during this appeal which have been diagnosed as or attributed to narcolepsy. Thus, the Veteran has not demonstrated that he has current narcolepsy, or even recurrent and persistent symptoms referable to narcolepsy. Notably, moreover, the Veteran has not identified any in-service event, injury, or illness to which his complaints of narcolepsy may be related, and there is nothing to even suggest the existence of any etiological relationship between the Veteran's post-service complaints of symptoms of narcolepsy and his military service. See McLendon, supra. Simply stated, remand of this claim for an examination or to obtain a medical opinion under the circumstances here presented would be a useless act. The duty to assist is not invoked where "no reasonable possibility exists that such assistance would aid in substantiating the claim." See, e.g., Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); 38 U.S.C.A. § 5103(a)(2). Therefore, VA has no obligation to obtain a VA examination or medical opinion commenting upon the presence or etiology of the disability at issue. See 38 U.S.C.A. § 5103A(d); 3.159(c)(4); McLendon, 20 Vet. App. at 83. Furthermore, as for any direct assertions by the Veteran or his representative as to diagnosis or medical etiology, the Board finds that such assertions do not provide persuasive evidence in support of the claim. The medical matters of the diagnosis and etiology of narcolepsy are within the province of trained medical professionals. See Jones, supra. Although laypersons are competent to provide opinions on some medical matters (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), here, the specific matters of the diagnosis and etiology of the Veteran's claimed narcolepsy are complex medical matters that fall outside the realm of common knowledge of a layperson. See Jandreau, supra. As neither the Veteran nor his representative is shown to be other than a layperson without appropriate training and expertise, neither is competent to render a probative (i.e., persuasive) opinion as to the medical matter upon which this claim turns. See, e.g., Bostain, supra. Hence, the lay assertions in this regard do not constitute competent evidence, and, thus, have no probative value. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. §§ 1110, 1131; see also 38 C.F.R. §§ 3.303. Thus, where, as here, medical evidence does not support a finding that, fundamentally, the Veteran has-or at any point pertinent to this appeal, has had-the disability for which service connection is sought, there can be no valid claim for service connection. For all the foregoing reasons, the claim for service connection for narcolepsy must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against a required element for the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. B. Higher Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1 (2015); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. In this case, as the AOJ already assigned staged ratings for the Veteran's PTSD with ADHD, the Board must consider the propriety of the ratings assigned, as well as whether any further staged rating is appropriate. The ratings for the Veteran's PTSD with ADHD have been assigned under Diagnostic Code 9411. However, psychiatric disabilities other than eating disorders are actually rated pursuant to the criteria of a General Rating Formula. See 38 C.F.R. § 4.130 (2015). Under the General Rating Formula, a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Id. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit has explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas"-i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. When evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a) (2015). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b) (2015). Historically, psychiatric examinations frequently included assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). [Parenthetically, the Board notes that the revised DSM-5, which among other things, eliminates GAF scores, applies to cases certified to the Board after August 4, 2014. See 79 Fed. Reg. 45,093 (Aug. 4, 2014)]. At the outset, the Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A December 2009 SSA psychiatric evaluation report documents the Veteran's reports of difficulty getting along with others and maintaining relationships, as well as ongoing anger and problems sleeping. The examiner noted that the Veteran displayed some symptoms of delusion and fair to poor judgment, as well as difficulty focusing and "erratic emotional functioning." The evaluator concluded that the Veteran's psychiatric symptomatology would likely interfere with his ability to perform repetitive tasks and pose difficulty in getting along with co-workers. His GAF score was assessed as 48 at the time. In January 2010, further SSA evaluation found the Veteran to have marked difficulty maintaining attention or concentration, performing activities on schedule, completing a normal workday or workweek without interruptions, and maintaining social functioning. The evaluation similarly reflects that the Veteran had a limited ability to interact appropriately with the public, accept instructions, and respond to criticism. He was noted at the time to display irritability and fair to poor judgment, as well as some symptoms of delusion and grandiosity. Treatment records dated in 2010 document that the Veteran was assigned a GAF score of 50 in February and March, although he was noted to have a euthymic mood and a normal mental status on both occasions. In May 2010, the Veteran reported that he was having difficulty focusing and trouble with sleep but otherwise made no complaints. On neuropsychiatric evaluation in July 2010, the Veteran reported that he had friends but that his relationship with his children was limited. He stated that he was hoping to earn a college degree and was going to Alcoholics Anonymous meetings. He complained of anger, depression, and anxiety, as well as occasional panic and difficulty concentrating. His mood was noted to be mildly anxious, and although mental status was normal, the Veteran was noted to be easily distracted and to have a low tolerance for frustration. His GAF score was assessed as 60 at that time. Later records from 2010 document that the Veteran reported that he continued to do well in school but continued to have difficulties with sleeping and depressed mood. His GAF score was assessed as 55 in August 2010. On VA examination in January 2011, the Veteran stated that his symptoms of PTSD with ADHD were mild to moderate on medication. He reported getting along with his parents and his sister and stated that he was making good grades in his classes. The examiner noted symptoms of flashbacks, avoidance, detachment, outbursts of anger and irritability, and difficulty concentrating. The Veteran was found to have fair impulse control and reported ongoing problems sleeping and a distant relationship with his children. His affect was noted to be constricted, and he reported that he often felt isolated. The examiner noted that the Veteran had had difficulty holding down jobs due to his anger. The Veteran was diagnosed with PTSD and ADHD, which the examiner found to have only transient or mild effects on his occupational and social functioning. His GAF score was assessed as 68. VA treatment records dated in 2011 document that the Veteran was assigned a GAF score of 60 in February 2011, at which time he reported that he had been sober for one year and was found to have a stable mood. His treatment provider found at that time that the Veteran was "able to concentrate very well and do very well in school and his life plan with the current treatment." Similarly, April 2011 treatment records reflect that the Veteran reported that he was earning good grades in his college classes but that he was "arrogant" and often irritable. He stated that he had been assigned a disability counselor to assist him at school. His GAF was assessed as 60 at those visits. In December 2011, the Veteran submitted a letter in which a private provider indicated that he had treated the Veteran since 2010 for PTSD and ADHD, which had worsened due to news events that caused the Veteran to become "increasingly irritable," including to strangers in public places. The physician stated that these increased symptoms had affected the Veteran's school and social life and had rendered him unable to "work full-time in any type of gainful employment." On VA examination in April 2012, the Veteran reported that he stayed in touch with his parents but not with his sister or his children. He stated that he had no friends or girlfriend, but did have a sponsor through Alcoholics Anonymous with whom he was in regular contact. He stated that he had been fired from his last job due to anger but that he was continuing to take some college classes, although he reported that he had a "C" average. He reported symptoms of nightmares, avoidance, detachment, irritability, and anxiety, as well as problems sleeping and concentrating. The examiner further observed suspicion, mild memory loss, impaired judgment, and difficulty establishing and maintaining effective work and social relationships. The examiner diagnosed the Veteran with PTSD and HDHD, assigning a GAF score of 60. However, the examiner found the Veteran to be "overendorsing symptoms at the time of the appointment" and thus declined to further evaluate the level of his service-connected psychiatric symptomatology. The Veteran again underwent VA examination in May 2013. At that time, he was again diagnosed with PTSD and ADHD and assigned a GAF score of 50. He reported that he had been kicked out of school for a semester due to his behavior and stated that he was "angry all the time," as well as anxious and nervous, and only slept about three to four hours per night. He reported that he did not have friends and mainly stayed at home, although he stated that school gave him a "positive focus" despite his ongoing struggles with attention and concentration. He stated that he had not been able to hold down a job or perform music due to anxiety. The examiner noted symptoms of avoidance, diminished interest and detachment, and a restricted affect, as well as hypervigilance, irritability, and anger outbursts. The Veteran was also found to have a depressed mood, panic attacks occurring weekly or less often, impaired judgment, and near-continuous panic or depression that affected his ability to function independently, appropriately, and effectively. The examiner stated that the Veteran had an inability to establish and maintain effective relationships, in addition to difficulty adapting to stressful circumstances. The examiner concluded that the Veteran's psychiatric symptomatology caused "severe" occupational and social impairment with deficiencies in most areas but did not lead to total occupational and social impairment. The Veteran also has submitted written lay statements. In his June 2011 NOD, he stated that he had panic attacks and experienced flashbacks causing fear and terror. He also stated that, at that time that he was unable to make friends and was in a disability services program at school. In February 2012, the Veteran's former employer submitted a statement indicating that the Veteran had been employed for a few weeks but had been terminated when he was unable to do the job or communicate with his co-workers. The Veteran submitted multiple statements in February 2012 similarly stating that he had difficulty working and interacting with others. Based on a review of the evidence of record, and resolving all reasonable doubt in the Veteran's favor, the Board first finds that, for the period from September 16, 2009, to December 7, 2011, an initial 50 percent, but no higher, rating is warranted. For this initial period under consideration, the medical evidence of record reflects that the Veteran's PTSD was manifested by symptoms such as the following: anxiety; outbursts of anger and irritability; difficulty establishing and maintaining effective relationships; chronic sleep disturbances; social isolation and avoidance; impaired judgment; constricted affect; and problems with attention and concentration. However, mental status examiners consistently found the Veteran to be alert and oriented to time, place, and person; and his speech and thought processes were normal. The Board finds that, collectively, these symptoms are of the type and extent, frequency, and/or severity (as appropriate) that suggest occupational and social impairment with reduced reliability and productivity. Thus, affording the Veteran the benefit of the doubt, the Board finds that the evidence indicates that the Veteran's PTSD with ADHD initially resulted in a level of occupational and social impairment which more closely approximates a 50 percent disability rating from September 16, 2009, to December 7, 2011. However, at no point during the period in question was the Veteran's PTSD with ADHD shown to result in occupational and social impairment with major deficiencies in most areas and an inability to establish and maintain effective relationships, or total occupational and social impairment. For example, from September 16, 2009, to December 7, 2011, the Veteran consistently denied active suicidal and homicidal ideation to both treatment providers and VA examiners, and his speech was never illogical, obscure, circumstantial, or irrelevant. There is further no indication that any behavior resulted in any effect upon the Veteran's routine activities, or that his anxiety or depression was near-continuous or affected his ability to function independently. Mental status examinations from the applicable time period consistently found the Veteran to be alert and oriented to time, place, and person, and there is no indication that the Veteran neglected his personal appearance or hygiene. Although the medical evidence of record clearly indicates that the Veteran suffered from problems associated with anger and irritability from September 16, 2009, to December 7, 2011, there is nothing to suggest that he was unable to control his impulses or was prone to periods of violence, such that his level of occupational and social impairment warranted a 70 percent rating. Further, to the extent that the Veteran's PTSD with ADHD resulted in symptoms of social avoidance and isolation, the Board finds that such symptomatology is contemplated by the 50 percent rating herein assigned. Because the Veteran's PTSD and ADHD symptoms from September 16, 2009, to December 7, 2011, were not of the type and extent, frequency, and/or severity (as appropriate) to indicate occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and mood-the level of impairment contemplated by the next higher, 70 percent disability rating-the Veteran's symptomatology also failed to rise to the level contemplated by the maximum 100 percent rating (which requires symptoms resulting in total occupational and social impairment). In reaching the above conclusions, the Board reiterates that the symptoms listed in the rating schedule under the criteria for the 50 percent rating, as well as higher 70 percent and 100 percent ratings, are essentially examples of the type and degree of symptoms indicative of the level of impairment required for each such rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013); Mauerhan, supra. However, as discussed above, the Board finds that, for the period from September 16, 2009, to December 7, 2011, the evidence of record simply does not show that the Veteran manifested symptomatology that is of the type, extent, frequency, and severity to result in a level of impairment that meets, or more nearly approximates, the level of impairment contemplated by any higher rating under VA's rating schedule. The Board also finds that, since December 7, 2011, the Veteran's PTSD and ADHD symptoms have not more nearly approximated the rating in excess of 70 percent under the General Rating Formula, as they have not been shown to be of such a severity or frequency as to result in total occupational and social impairment. The Veteran has not exhibited symptoms indicative of a 100 percent rating for the period from December 7, 2011, nor is there any evidence or medical opinion that the Veteran has been totally occupationally and socially impaired due to symptoms of the type, and extent, frequency and/or severity, as appropriate, as those delineated in the rating formula as indicative of the maximum rating. In this regard, since December 7, 2011, there has been no subjective or objective evidence of gross impairment to thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time or place, intermittent inability to perform activities of daily living, or memory loss for names of close relatives, own occupation, or own name. Also, the Veteran has consistently denied active suicidal and homicidal ideation or plan at each VA examination conducted during this period and in all the treatment records during the relevant period. None of the psychiatrists or psychologists of record have found him to be a persistent risk for suicide or for harming others. Moreover, the evidence does not reflect symptoms of the type, and extent, frequency and/or severity ( as appropriate), that demonstrate total social impairment. The Veteran's reports to physicians show that he has had a good relationship with his Alcoholics Anonymous sponsor and with his parents. Thus, although his social support system has been limited, it does exist. Thus, the Board finds that, for the period beginning on December 7, 2011, the Veteran's psychiatric symptoms and functional impairment fall into the moderate to severe range, and his PTSD with ADHD is not shown to have resulted in more than occupational and social impairment with deficiencies in most areas. Accordingly, his symptoms have most closely approximated the currently assigned 70 percent rating, rather than the maximum, 100 percent rating. Therefore, the Board finds that the Veteran is not entitled to a disability rating in excess of 70 percent for his PTSD with ADHD from December 7, 2011. The Board further finds that none of the GAF scores assigned during any period under consideration, alone, provides a basis for assignment of any higher rating. In this case, as noted, during the relevant time periods, the Veteran was assigned GAF scores ranging from 48 to 68. Under the DSM-IV, GAF scores from 61 to 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household) but generally functioning pretty well, has some meaningful interpersonal relationships. Scores 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Clearly, the assigned scores above 50 are suggestive of even less impairment than that contemplated in the 70 percent rating. However, even the lowest score of 48 suggests a level of impairment commensurate with the assigned rating. Thus, although varying, the Board finds that these assigned GAF scores are consistent with no more than the level of impairment contemplated by the 70 percent rating ,and do not provide a basis for any higher rating for any period in question. The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the Veteran's PTSD with ADHD been shown to be so exceptional or so unusual a picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). See also Thun, supra. If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). See 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. See Thun, supra. Here, the Board finds that the applicable rating criteria for PTSD reasonably describe the Veteran's disability levels and symptomatology throughout the course of the periods on appeal and provide for additional or more severe symptoms than currently shown by the evidence. The Board also notes that it has considered all psychiatric symptomology in determining the Veteran's functional impairment, not just the symptoms listed in the rating criteria. See Mauerhan, 16 Vet. App. 436. The Board further acknowledges that the Veteran's PTSD with ADHD has impacted his ability to work but notes that such factor is contemplated in the rating criteria, which consider the effects of PTSD symptomatology on both occupational and social functioning. In short, the Veteran's disability picture for each time period under consideration is contemplated by the rating schedule, and the assigned schedular ratings are, therefore, adequate. See Thun, 22 Vet. App. at 115. The Board further notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir., 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the appeal only involves evaluation of PTSD with ADHD, appropriately evaluated as a single disability. As the Board has fully considered the functional effects of the Veteran's PTSD with ADHD in evaluating the disability, and the evaluation of multiple service-connected disabilities is not presently at issue, the Board finds that the holding of Johnson is inapposite here. Thus, the requirements for invoking the procedures set forth in 38 C.F.R § 3.321(b)(1) are not met, and referral of the Veteran's increased-rating claim for extra-schedular consideration is not required. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds that the record presents no basis for staged rating of the Veteran's PTSD with ADHD, pursuant to Fenderson, and that, affording the Veteran the benefit-of-of the doubt, an initial 50 percent rating is warranted from September 16, 2009, to December 7, 2011, but that the preponderance of the evidence is against assignment of a rating in excess of 70 percent from December 7, 2011. See 38 U.S.C.A § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for narcolepsy is denied. An initial, 50 percent disability rating for PTSD with ADHD, from September 16, 2009, to December 7, 2011, is granted, subject to the legal authority governing the payment of compensation. A disability rating in excess of 70 percent for PTSD is denied. REMAND The Board's review of the claims file reveals that further AOJ action is warranted on the matter of the Veteran's entitlement to a TDIU due to his PTSD with ASHD for the period from September 16, 2009, to December 7, 2011, is warranted. The Veteran's electronic claims file includes records of private and VA treatment he received from September 2009 to December 2011. He was noted in December 2009 to have difficulty "sustaining at least two hours of repetitive tasks" due to his psychiatric disability, which was noted to be likely to cause interpersonal problems with co-workers. Similarly, at a January 2010 SSA evaluation, the Veteran was noted to display marked limitation with maintaining attention and concentration for extended periods and completing a normal workday or workweek without interruptions. VA treatment records from later in 2010 reflect that the Veteran reported having enrolled in school. Similarly, at a January 2011 VA examination, he reported that he was in school making good grades but had been unable to hold down jobs due to problems with anger. Multiple records from 2011 document the Veteran's report of earning "very good grades," although he stated in April 2011 that he was having difficulty focusing in class and had been assigned a disability counselor to help him at school. However, the Veteran's former employer submitted a statement in February 2012 indicating that the Veteran had been employed for a few weeks in 2010 but had been terminated because he was unable to perform the required work or communicate with his co-workers. The Veteran has further stated that his inability to work is due to his service-connected PTSD with ADHD. As noted above, the Veteran has been awarded a TDIU effective from December 7, 2011, due to his service-connected PTSD with ADHD. However, the Veteran has asserted, and evidence of record suggests, that his unemployability due to PTSD with ADHD may have begun prior to that date. Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2015). However, a total rating may nonetheless be assigned on an extra-schedular basis in exceptional cases (and pursuant to specifically prescribed procedures) when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b) (2015). Here, for the period from September 16, 2009, to December 7, 2011, the Veteran's service-connected PTSD with ADHD does not meet the percentage requirements for a schedular TDIU, as the assigned rating is less than 70 percent. See 38 C.F.R. § 4.16(a) (2015). However, the collective evidence of record suggests that the Veteran has been unemployed and unemployable since, possibly, as early as 2009. The Board thus finds that this case meets the criteria for referral of the claim to the first line authority for consideration of an extra-schedular rating, as there is competent evidence suggesting that the Veteran may have been unable to secure or follow a substantially gainful occupation due to his service-connected PTSD with ADHD from September 16, 2009, to December 7, 2011. See 38 C.F.R. § 4.16(b); see also Bowling v. Principi, 15 Vet. App. 1, 9-10 (2001) (holding that the Board could not award TDIU on an extra-schedular basis without first ensuring that the claim was referred to the appropriate first line authority for such consideration). Therefore, the Board is remanding the remaining matter on appeal for additional development, to include referral of the claim to the appropriate first line authority-VA's Chief Benefits Director or the Director of VA's Compensation Service-for a determination as to the Veteran's entitlement to an extra-schedular TDIU from September 16, 2009, to December 7, 2011. Prior to undertaking action responsive to the above, to ensure that all due process requirements are met, and the record is complete, the AOJ should also give the Veteran another opportunity to provide pertinent information and/or evidence pertinent the claim for a TDIU due to PTSD with ADHD prior December 7, 2011. The AOJ's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2014); but see 38 U.S.C.A. § 5103(b)(3) (West 2014) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the AOJ should obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the remaining matter on appeal. Accordingly, this matter is hereby REMANDED for the following action: 1. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to obtain any additional evidence pertinent to the matter of his entitlement to a TDIU due to PTSD with ADHD, prior to December 7, 2011, that is not currently of record. Specifically request that the Veteran furnish, or furnish provide appropriate authorization to obtain, all pertinent private (non-VA) medical records, as well as any employment records, pertinent to this period. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records and responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses from each contacted entity are associated with the claims file, or a reasonable time period for the Veteran's response has expired, submit to VA's Chief Benefits Director or the Director of VA's Compensation Service the matter of the Veteran's entitlement to an extra-schedular TDIU due to PTSD with ADHD prior to December 7, 2011. 4. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After accomplishing all requested action, as well as any additional action deemed warranted, adjudicate the matter of the Veteran's entitlement to a TDIU due to PTSD with ADHD, to include on an extra-schedular basis, prior to December 7, 2011, in light of all pertinent evidence and legal authority. 6. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs